Heparin vs. bivalirudin during PCI yields conflicting results

LAS VEGAS — Two studies presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions came to different conclusions on whether bivalirudin or heparin produces better outcomes in patients undergoing PCI.

One study, covering a wide range of patients, found that those given heparin had better bleeding and mortality outcomes compared with those given bivalirudin (Angiomax, The Medicines Company). Another study, covering patients with diabetes, found that patients given bivalirudin had better outcomes related to bleeding and net adverse cardiac events compared with those given heparin plus a glycoprotein IIb/IIIa inhibitor (GPI).

Heparin favored in health system

For the first study, Charles Cannan, MD, of Providence Heart and Vascular Institute, Portland, Ore., and colleagues analyzed data from 14 hospitals in the Providence Health System on patients who underwent PCI between July 2009 and September 2013.

Charles Cannan

At one hospital, all patients (no-bivalirudin group, n=2,495) received moderate-dose heparin (80 U/kg), plus a bolus only of a GPI when needed. At the other 13 hospitals, bivalirudin was used preferentially on patients (pro-bivalirudin group, n=29,736) undergoing PCI; in 73% of cases, operators used bivalirudin.

After controlling for patient risk, Cannan and colleagues found that the no-bivalirudin group had lower in-hospital mortality (OR=0.54; P<.001) and lower rates of in-hospital bleeding (OR=0.22; P<.001) compared with the pro-bivalirudin group.

In addition, the researchers estimated that the 13 hospitals using a bivalirudin-preferred strategy would have saved a combined $10.7 million had they used heparin exclusively during the study period.

“There were no disadvantages in mortality or bleeding that we could find to using moderate-dose heparin,” Cannan said in a press release. “Bivalirudin is easy to use and very predictable, but its cost is so much more, and there’s no apparent benefit to patients in our system.”

Bivalirudin favored in diabetics

For the second study, Oluwaseyi Bolorunduro, MD, MPH, from the University of Tennessee Health Sciences Center, and colleagues performed a meta-analysis of data from seven randomized controlled trials evaluating bivalirudin vs. heparin plus GPI in 7,178 patients with diabetes undergoing PCI.

Oluwaseyi Bolorunduro

The primary outcome was net adverse cardiac events, defined as major bleed and composite ischemia, at 30 days and 1 year.

At 30 days, use of bivalirudin was associated with reduced net adverse cardiac events (RR=0.84; P=.01) and reduced major bleeding (RR=0.69; P=.02) compared with use of heparin plus GPI. Bolorunduro and colleagues found no difference between the groups in composite ischemia (RR=0.92; P=.44) or all-cause mortality (RR=0.71; P=.15). At 1 year, however, bivalirudin use was associated with lower mortality (RR=0.73; P=.05) despite similar rates of composite ischemia (RR=0.98; P=.71).

“Diabetics don’t need to be treated any different from other patients in terms of the anticlotting medications we use during PCI,” Bolorunduro said in a press release. “Bivalirudin is better than heparin for these patients, with less bleeding at 30 days and a lower risk of death at 1 year.” – by Erik Swain

For more information:

Bolorunduro O. Abstract A-071.

Cannan C. Abstract C-049. Both presented at: the Society for Cardiovascular Angiography and Interventions Scientific Sessions; May 28-31, 2014; Las Vegas.

Disclosure: Bolorunduro and Cannan report no relevant financial disclosures.